Pain control and reduction of opioid use associated with intracameral phenylephrine1.0%-ketorolac 0.3% administered during cataract surgery

PURPOSE

To compare pain and the need for the opioid fentanyl use associated with the administration of phenylephrine 1.0%-ketorolac 0.3% (P/K) with those of epinephrine administration during cataract surgery.

SETTING

Ambulatory surgery center.

DESIGN

Single-center, prospective, randomized, double-masked, self-controlled trial.

METHODS

Patients undergoing bilateral, topical anesthetic cataract surgery were randomized to receive either intracameral P/K or epinephrine in their balanced salt solution for the first eye and the other for the second eye, 2 weeks later. Fentanyl was used to manage intraoperative pain. The primary end point was the need for fentanyl administration intraoperatively. Secondary outcomes included pain measurements; surgery duration; effective phacoemulsification time; pupil size; and complications.

RESULTS

112 eyes of 56 patients were enrolled. Significantly fewer eyes in the P/K group (7 [12.5%]) than in the epinephrine group (19 [33.9%]; P = .013) required intraoperative fentanyl administration. Mean pain scores were lower in the P/K group than those in the control group at all timepoints. For patients with no pain to mild pain (pain scores ≤ 3), 85.7% (n = 48) of the P/K group and 58.9% (n = 33) of the epinephrine group met this benchmark ( P = .003) intraoperatively. The combined outcome, the number of patients not receiving intravenous fentanyl and experiencing no pain to mild pain, was significantly higher in the study (82.1%, n = 46) than in the control group (58.9%, n = 33; P = .013).

CONCLUSIONS

P/K administration significantly reduced pain and the need for fentanyl use. Using P/K is a practical way for cataract surgeons to provide better patient care and reduce the need for intraoperative opioids.

Cataract surgery in small pupils

This paper presents the review of historical aspects and the current state-of-the-art in various pupil dilatation methods to be used in cataract surgery. The surgical algorithm in managing small pupil cases should include topical and intraocular mydriatics, appropriately selected viscosurgical device and mechanical dilatation with instruments, iris hooks, and/or pupil expanders.

Recent advances in small pupil cataract surgery

PURPOSE OF REVIEW

To highlight the existing and emerging cataract surgery trends in patients with insufficient mydriasis. Discuss the latest pharmacological approaches for pre and intraoperative pupil dilatation. Present the variety of newest pupil expansion devices; critically review their advantages and possible limitations to be considered by the surgeon.

RECENT FINDINGS

The intracameral use of various mydriatic combinations augmenting the preoperative mydriatic instillations is currently gaining popularity in cataract surgery. Two main options are available: bolus injection of pharmacological agent or its constant irrigation during the phacoemulsification procedure. The former is aimed to expand the pupil, whereas the latter is mostly preventing the pupil from constriction. Introduction of femtosecond-assisted cataract surgery, apart from some benefits was followed by a variety of adverse effects including prostaglandin release into the aqueous humor causing pupil constriction. Preoperative administration of nonsteroidal anti-inflammatory drugs at least 1 day prior to surgery significantly decreases the chance of pupil constriction after laser energy is applied to the eye. However, pupil expansion devices may be needed in up to 10% of cases. Following the success of the Malyugin ring (MicroSurgical Technology Inc., Redmond, Washington, USA) several manufacturers introduced pupil expansion devices of various designs. They are differing with materials, pupillary margin fixation mechanisms, and easiness of manipulations during implantation and removal.

SUMMARY

Combination of proper use of pre and intraoperative pharmacological pupil dilatation protocols combined with pupil expander rings allow for well tolerated and effective cataract surgery in the vast majority of patients with insufficient mydriasis.

Intracameral Use of Nepafenac: Safety and Efficacy Study

PURPOSE

To test the intracameral safety of nepafenac and its efficacy in inhibiting prostaglandin synthesis during phacoemulsification surgery.

METHODS

The safety evaluation was conducted in normal eyes of rabbits, 0.1ml of 0.3% and 1% nepafenac was injected intracamerally. Extensive studies to detect adverse response ranged from a gross examination of eyes under slit lamp biomicroscope, fluorescein dye test, Schirmer tear test, test for corneal sensitivity, intraocular pressure measurement (IOP), specular microscopy, electroretinography(ERG), and histopathological examination of intraocular tissues. Efficacy of nepafenac was studied by intracameral injection of 0.1%, 0.3% nepafenac, nepafenac 0.3%+1% lignocaine, and 1% lignocaine alone, before phacoemulsification surgery and intraoperative mydriasis along with PGE2(ProstaglandinE2) secretion were recorded.

RESULTS

Single 0.1ml of 0.3% or 1% nepafenac did not significantly (p > 0.05) alter physiological parameters and histology of cornea, iris, and retina. Nepafenac 0.3% effectively inhibited PGE2 secretion. No significant (p > 0.05) prevention of miosis was recorded with 0.1% or 0.3% nepafenac. However, a combination of 0.3% nepafenac + 1% lignocaine and 1% lignocaine alone significantly (p < 0.05) arrested miosis during the intraoperative period.

CONCLUSION

An intracameral concentration of up to 1% nepafenac does not adversely affect the rabbit eye. Nepafenac fails to prevent miosis but inhibits prostaglandin release during phacoemulsification surgery.